Chronic Care Management
Optimized for multi-comorbidity patients with conditions like COPD, arthritis, and GI disease
JessicaHerbert/ccm-activity-tracker
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Resources
Evaluation of a Chronic Care Management Model for Improving Efficiency and Fiscal Sustainability
Peer-reviewed evaluation of an expanded ambulatory CCM team (provider, nurse, community health worker, pharmacist) delivering a four-month intervention to 134 Medicare patients with uncontrolled type 2 diabetes or hypertension. Showed statistically significant improvements in diabetes control (P < .01) and blood pressure control (P < .001), while reducing direct provider workload and achieving an 85.5% Medicare reimbursement rate. Supports the case that CCM delivered with automated workflows produces measurable clinical outcomes and is fiscally sustainable for ambulatory practices.
View Resource PaperUse of Chronic Care Management Among Primary Care Clinicians
Peer-reviewed analysis of Medicare claims data showing how primary care clinicians adopted CCM services after the 2015 CMS benefit. CCM use by primary care physicians grew from 810,289 services in 2015 (~$33.7M in payments) to 3,401,546 services in 2018 (~$151.9M in payments). Primary care physicians delivered 78% of all CCM services, compared with 8% from medicine subspecialties. Supports the case that CCM is an ambulatory, primary care-led revenue stream that scales with workflow automation.
View Resource Paper